Specific Stop-Loss (SSL) Pricing
Stop-Loss coverage provides liability limits on claims for individuals and for the employer group as a whole. Specific Stop-Loss (SSL) is the form of excess risk coverage that provides protection for the employer against a high claim on any one individual. This is protection against abnormal severity of a single member claim rather than abnormal frequency of claims in total. Specific stop-loss is also known as individual stop-loss. The specific stop-loss is calculated on the claim transactions received for an individual.
You can define a specific stop-loss pricing rule at the parent customer and bill group levels. The specific stop-loss pricing rule at the bill group level takes precedence over the specific stop-loss pricing rule at the parent customer level. You can define specific stop-loss pricing rules for parent customers and bill groups from the Customer 360° Information screen. You can define a specific stop-loss pricing rule using a specific stop-loss pricing rule type.
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Business object using which the specific stop-loss pricing rule should be created in the system.
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Algorithm which should be triggered while validating a transaction.
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Algorithms which should be triggered while deriving account and price item for a transaction.
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Post-processing algorithm which should be triggered once the specific stop-loss pricing rule is derived.
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Price items for which you can define specific stop-loss pricing rules using the specific stop-loss pricing rule type.
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Rate options that you can use while defining the pricing for a price item.
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Different type of account to which the price item should be billed based on the specified priority.
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Additional information, such as:
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Identifier which helps to determine whether the specific stop-loss should be calculated for claim transactions which are received during the run-in period of the policy.
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SSL billable charge line type using which you want to create specific stop-loss billable charges.
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Domestic provider claim billable charge line type using which you want to create domestic provider claim calculation lines.
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Markup or markdown billable charge line type using which you want to create markup or markdown calculation lines.
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Transaction field which you want to use in the rules as the output parameter to determine whether the line item is eligible for billing.
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Transaction field which you want to use in the rules as the output parameter to determine whether the markup or markdown calculation line is eligible for billing.
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Transaction field which you want to use in the rules as the output parameter to determine whether the domestic provider claim calculation line is eligible for billing.
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Price item for which you want to define the pricing.
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Pricing date range during which the pricing is effective.
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Rate option which you want to use while defining the specific stop-loss pricing.
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Whether the specific stop-loss pricing rule must be used for only pricing or for pricing and billing.
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Whether the specific stop-loss must be accumulated at the member or main subscriber level.
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Settlement frequency which helps to determine the bill after date. The valid values are:
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Immediately – If you select this option from the list, the bill after date is not calculated. The specific stop-loss billable charge is billed immediately in the next bill cycle.
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Manually (At Required Intervals) - If you select this option from the list, the bill after date which is specified in the Manual Settlement Bill After Date parameter while executing the C1-BCSSL batch is stamped on the specific stop-loss billable charge.
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Never - If you select this option from the list, the bill after date which is specified in the Manual Settlement Bill After Date parameter while executing the C1-BCSSL batch is stamped on the specific stop-loss billable charge.
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Yearly – If you select this option from the list, the bill after date in the specific stop-loss billable charge is set to the pricing end date.
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Accumulation parameters (such as incurred start date, incurred end date, paid start date, paid end date, etc.) based on which you want to accumulate the specific stop-loss for the claim transactions which are processed in the run-in or active period of the policy.
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The maximum limit defined for specific stop-loss at the member or main subscriber level.
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Settlement days which helps to calculate the settlement date (i.e. pricing end date, incurred end date, or paid end date whichever is later + settlement days)
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Whether the Aggregate Specific Stop-Loss (ASSL) should be calculated during the C1-BCSSL batch run for each bill group
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The ASSL limit indicating that the aggregate specific stop-loss amount beyond this limit will be paid by the insurance company to the ASSL credit account.
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Whether any member, main subscriber, or provider is excluded during the specific stop-loss calculation Different SSL limit (i.e. lasered amount) for a member, main subscriber, or provider who are expected to have higher claim amount.
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The status of the policy for which you want to define the specific stop-loss pricing rule.
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Price item for which you want to define the pricing.
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Parent customer’s SSL pricing rule from which you want to inherit the accumulation parameters and exclusion and lasering information.
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Rate option which you want to use while defining the specific stop-loss pricing.
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Whether the specific stop-loss calculated for the claim transactions which are mapped to the specified price items and price item parameters should be accumulated.
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The SSL limit indicating that the specific stop-loss amount beyond this limit will be paid by the insurance company.
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The maximum specific stop-loss limit defined for the member when the claim transactions are received in the run-in period of the policy.
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Whether line items in a claim pricing rule are eligible for specific stop-loss
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Whether certain percentage of SSL should be excluded while calculating specific stop-loss for domestic provider claim.
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Whether the specific stop-loss calculated for the claim transactions which are mapped to the specified price items and price item parameters should be accumulated.
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The SSL limit indicating that the specific stop-loss amount beyond this limit will be paid by the insurance company.
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The maximum specific stop-loss limit defined for the member when the claim transactions are received in the run-in period of the policy.
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Whether line items in a claim pricing rule are eligible for specific stop-loss.
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Whether certain percentage of SSL should be excluded while calculating specific stop-loss for domestic provider claim.
Once a specific stop-loss pricing rule is defined for a parent customer and bill group, the system creates one price assignment, one price list, and one price list assignment.
Related Topics
For more information on... | See... |
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Pricing Rule Type screen | Pricing Rule Type |
Parent Topic: Self-Funded Pricing